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The Ergonomic Challenges Students Face during Operative Dentistry

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Preprint  in  Journal of Clinical and Diagnostic Research · August 2021

DOI: 10.7860/JCDR/2021/48521.15256

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DOI: 10.7860/JCDR/2021/48521.15256
The Ergonomic Challenges Students Face
Dentistry Section
during Operative Dentistry Treatment
MARIUS G BUD1, Sergiu Spataru2, Razvan Pop3, Razvan Pricope4,
Ondine Lucaciu5, Sanda Campean6, Ada Delean7
ABSTRACT
Introduction: Students must possess good theoretical knowledge
in order to perform correct clinical treatments with good prognosis
and in safe conditions but merging theoretical knowledge and
clinical practice in dental education is a challenge for both the
training staff and the students. Up until now, no studies have
been published in our country regarding the challenges faced by
dental students in their clinical works performance for restorative
dentistry and endodontic treatments.
Aim: The aim of this study was to assess the factors that
may influence the performance of restorative and endodontic
treatment procedures performed by 5th year dental students
and their own perception on clinical work.
Materials and Methods: This was a cross-sectional study
carried out in February 2020. A self-made questionnaire  with
13 questions was distributed via e-mail link to 5th year  dental
students  at the University of Medicine and Pharmacy Iuliu
Hat‚ieganu Cluj Napoca, Romania, Department of Conservative
Dentistry, all 5th year dental student who had previously
undergone two years of clinical training. One hundred eleven
(n=111) students were selected after applying the inclusion
criteria that were, having two years of clinical training experience
and having passed their theoretical ergonomics, restorative
Keywords: Dental students, Difficulties, Endodontics, Posture, Rubber dam, Self-perception
INTRODUCTION
Dentistry is considered by most students to be a difficult study
program. Statistics say that 80% of students pursuing dental school
feel that they were not adequately prepared for the course at the
time of joining the faculty [1].
Students must possess good theoretical knowledge in order to
perform correct clinical treatments with good prognosis and in safe
conditions, but merging theoretical knowledge and clinical practice
in dental education is a challenge for both the training staff and the
students [2]. The application of the acquired theoretical knowledge
in practice is imperative for a good diagnosis, treatment planning
and treatment itself. This may be difficult to achieve in the absence
of the necessary expertise. Moreover, a mutually satisfying dentist-
patient relationship has many benefits including improved patient
compliance and better therapeutic results. Lack of knowledge,
clinical experience and communication skills may generate
challenges for dental students in their first clinical years of training in
restorative dentistry and endodontics [3].
Knowing and applying the rules of postural ergonomics to allow
an optimal working position during clinical training is of utmost
importance [4]. Roughly, one third of students suffer from
musculoskeletal disorders of the head and neck due to incorrect
working position, some studies reporting even higher percentages up
to 71% [5,6]. When the principles of dental ergonomics are applied
correctly, lead to a reduction in the prevalence of musculoskeletal
Journal of Clinical and Diagnostic Research. 2021 Aug, Vol-15(8): ZC33-ZC37
Original Article
dentistry and endodontics examinations. Descriptive Statistics
were used for data analysis.
Results: The majority of the students 83% (n=92) encountered
difficulties applying the rules of ergonomics related to posture.
The most common causes that prevented students from
applying the rules of ergonomics during the clinical work were
challenges related to working in indirect vision (n=90), lack
of help by an assistant during treatment (n=52), working time
allocated being too short (n=50), lack of sufficient space around
the unit (n=43). Regarding the theoretical level required for
restorative cases diagnosis, treatment plan and treatment itself,
64% (n=71) of students claimed to have had the necessary
theoretical knowledge in most cases they met and only 25%
(n=28) could confidently treat all cases. Establishing the
diagnosis and treatment plan for endodontic cases was difficult
stage for 4% (n=4) of students, of average difficulty in the case
of 81% (n=90) of students, while 15% (n=17) did not consider
them difficult at all.
Conclusion: The results indicated that students had high levels of
confidence in their theoretical knowledge when establishing the
diagnosis and the treatment plan, but they encountered multiple
challenges both with working ergonomically and with mastering
the practical skills needed in different stages of the treatment.
disorders among dentists [7]. However, it seems like students find it
difficult to put these principles into practice.
Using a rubber dam may increase both the quality of the treatment
and students’ focus during treatment. Despite these, undergraduate
students don’t use it for all endodontic or restorative treatments
[8]. Assessing the quality of endodontic fillings performed by
undergraduate students, a previous study estimated that only
49% of monoradicular and 17% of pluriradicular treatments could
be qualified as appropriate [9]. Similar studies report varying
percentages in the evaluation of good quality treatment in posterior
teeth, ranging from 24.2% to 46.6% [10-12]. These results are far
from satisfactory, due to the limited clinical practice of students
[13] and are influenced by multiple specific challenges, including:
lack of clinical experience and practical craftsmanship, the high
ratio of students/supervising-dentists; knowledge and observance
of therapeutic protocols and existence of appropriate technical
equipment [14]. Supervising dentists can help by using appropriate
teaching methods [15].
All the factors above can significantly influence the way in which
students perform clinical treatments in the spirit of respecting
the principles of ergonomics and obtain qualitatively satisfactory
treatments. Up until now only one previous study exists from North-
East Romania regarding the general attitude and knowledge of
dentists towards ergonomics [16]. Therefore, this study was carried
out in North-West Romania. The aim of this study was to assess
33
 Marius G Bud et al., The Ergonomical Challenges Students Face while Working in a Clinical Setting www.jcdr.net
the factors that may cause difficulties or influence the performance
of students while working on restorative and endodontic treatments
and to evaluate their own perception on their clinical work.
MATERIALS AND METHODS
This was a cross-sectional study carried out in the Department of
Conservative Dentistry at the University of Medicine and Pharmacy,
Iuliu, Hat‚ieganu Cluj, Napoca, Romania, in February 2020 on dental
students who had previously undergone two years of clinical training.
Inclusion and Exclusion criteria: One hundred eleven students
were selected after applying the inclusion criteria: having two years
of clinical training experience and having passed their theoretical
Ergonomics, Restorative Dentistry and Endodontics examinations.
No other exclusion criteria were applied.
The questionnaire was designed both by a dental student and by a
university assistant from the Department of Conservative Dentistry
with 10 years of experience. It was focused on identifying student
difficulties during clinical work related to dental ergonomics, rubber
dam management, level of theoretical knowledge, clinical problems,
and administrative problems. The initial questionnaire draft was
checked by a senior faculty member and modified according to
the feedback. It contained two demographics questions regarding
sex and age, and 13 main questions, with various designs:
dichotomous (yes/no), Likert scale and single response multiple
choice questions.
Students were assured of the anonymity and confidentiality of their
survey responses. The questionnaire was distributed by email via
link form, in Romanian language. The online link for the questionnaire
was given for completion for students on 10th Feb. 2020 and it was
closed on 24th Feb 2020.
statistical analysis
The results were tabulated using Microsoft Excel and descriptive
statistics were used.
RESULTS
The questionnaire had 111 respondents in total. Thirty-seven of
them were males and 74 were females. Ninety-seven students
had ages which ranged from 20 to 25, while 14 of them had ages
ranging from 26 to 35. The demographic details are presented in
[Table/Fig-1].
Demographics Total Number (n) Percentage
Age (years)
20-25 97 87.3%
26-35 14 12.7%
Gender
Male 37 33.3%
Female 74 66.6%
[Table/Fig-1]: Demographic of students (N=111).
Posture and Ergonomics
The majority of the students 83% (n=92) encountered difficulties
applying the rules of ergonomics related to posture and only 17%
(n=19) had no problem in this field [Table/Fig-2]. For measuring
the satisfaction reported by students regarding their own posture,
the questionnaire had a Likert scale, with choices that ranged
from 1-very dissatisfied to 5-very satisfied [Table/Fig-2]. Posture
satisfaction scores can be seen in [Table/Fig-3].
The most common causes that prevent students from applying
the principles of ergonomics related to posture during clinical work
were as follows: working in indirect vision (n=90), lack of help by
an assistant during treatment (n=52), working time allocated being
too short (n=50), lack of sufficient space around the unit (n=43)
[Table/Fig-2].
34
Fifteen percent of students (n=16) reported that they were always or
most of the times prevented from following the ergonomic principles
due to patient-related causes, but the majority (68%, n=76) only
face this problem sometimes) [Table/Fig-2].
The most common patient-related challenges were: lack of patient
cooperation (rushed patient, long-term treatment, high level of
stress, low level of comfort, not tolerating the instruments used)
(n=67); the patient’s physical condition (inability of the patient to
open the mouth,  general illness, respiratory difficulties, vomiting
reflex) (n=27); patient’s stature (too tall, overweight) (n=6) [Table/
Fig-2]. Regarding using indirect vision during treatments for
maxillary and mandibular teeth, the results can be seen in.
Rubber Dam
When applying the rubber dam system, nearly half of the students
(n=55) sometimes faced difficulties. Almost half (n=47) did not
encounter difficulties and only a few (n=9) do not use the rubber
dam system at all for clinical treatments [Table/Fig-2].
Case Analysis and the Treatment Protocol
Regarding the theoretical level required for restorative cases
diagnosis, treatment plan and treatment itself, 64% (n=71) of
students claimed to have had the necessary theoretical knowledge
in most cases they met and only 25% (n=28) could confidently treat
all cases [Table/Fig-2]. The clinical difficulty of previous restorative
treatments reported by students can be seen in.
Establishing the endodontic diagnosis and the treatment plan was
considered difficult by only 3.6% (n=4) of students, of average
difficulty in the case of 81% (n=90), while 15% (n=17) did not
consider it difficult at all.
There were also factors that prevented students from obtaining
the expected results from the treatments. A 10% (n=11) of
students reported that they didn’t possess sufficient theoretical
knowledge or didn’t respect all the treatment protocol steps. A
47% (n=53) considered the case to be too difficult for their clinical
experience, while 17% (n=19) reported they lacked sufficient
guidance from the supervising stage assistant. A 15% (n=17)
could not properly choose or organise their instruments before
and during the procedures, while 10% (n=11) reported that they
faced no difficulties [Table/Fig-2].
Sometimes, difficult access to the posterior teeth, atypical
internal anatomy or lack of time and experience can increase the
treatment’s level of difficulty. In the aforementioned cases, the
students appreciate that they do not obtain the desired results, the
treatments being too difficult for their clinical experience (3% of the
respondents) [Table/Fig-2].
When questioned about the time dedicated to the adjacent
and administrative activities related to dental treatments,
the most time-consuming activity reported by students was
completingthe  paper-work-29% (n=32), followed by taking
dental X-rays-25% (n=28), setting up the dental chair and the
armamentarium-16% (n=18) and lastly scheduling patients and
communicating with them-11% (n=12). However, 10% (n=11)
of the students reported that there are no timing consuming
activities [Table/Fig-2].
DISCUSSION
This study evaluated the answers of 111 students with two years
of clinical training who answered a questionnaire regarding the
challenges encountered while performing restorative and endodontic
treatments and their compliance with the principles of ergonomics
while working.
The majority of students 83% (n=92) found it hard to comply with the
rules of ergonomics related to position and posture during clinical
Journal of Clinical and Diagnostic Research. 2021 Aug, Vol-15(8): ZC33-ZC37
www.jcdr.net Marius G Bud et al., The Ergonomical Challenges Students Face while Working in a Clinical Setting

Nr. Crt. Question Responses

Do you encounter any difficulties in respecting the Yes No
1 ergonomic principles for an ideal working posture? Yes/
no 92 19

On a 1 to 5 scale, how satisfied are you with your 1 2 3 4 5

2
working posture? 1-very dissatisfied, 5-very satisfied 3 15 53 35 5
1* 2* 3* 4*
3 If yes, please choose from the following
90 52 43 50

Are there any patient-related causes that prevent you Never Sometimes Most of the times Always
4
from applying the ergonomic rules for posture? 19 76 14 2
Please choose the frequent patient-related causes 1** 2** 3** 4**
5 that prevent you from applying the ergonomics rules of
posture while treating endodontic cases: 67 27 6 11

For treating maxillary teeth, how often do you work Never Sometimes Most of the times Always
6
using indirect vision? 4 55 39 13

For treating mandibular teeth, how often do you work Never Sometimes Most of the times Always
7
using indirect vision? 33 64 12 2

Do you encounter any difficulties in applying the rubber Never Sometimes I don’t use the rubber dam for endodontics treatments
8
dam system? 47 55 9

How often did you think you had all the theoretical In all cases Most of the cases Approximately half the cases Sometimes never
9
knowledge for treating and diagnosing the case? 28 71 9 3 0

How would you evaluate the level of clinical difficulty of Not difficult Average difficulty Difficult
10
your previous restorative treatments? 40 70 1

How difficult is it for you to diagnose and establish a Not difficult Average difficulty Difficult
11
treatment plan for endodontic cases? 4 90 17

What was the factor that stopped you from obtaining 1*** 2*** 3*** 4*** 5***
12
the expected results from the treatment? 11 53 19 17 11

Which activity secondary to the actual dental treatment 1**** 2**** 3**** 4**** 5****
13
do you feel is most time-consuming? 18 32 12 38 11
1* Inability to obtain optimal vision when working with the mirror 2*** Case difficulty level to high for my clinical experience

2* Lack of assistance while working 3*** Not enough guidance from the supervising dentist

3* Lack of sufficient space around the dental unit 4*** Poor choice and organisation of armamentarium before and during the procedure

4* Not enough time to complete the treatment 5*** No difficulties

Lack of cooperation with the patient (rushed patient, treatment

1** session too long, high stress level of patient, patient not 1**** Setting up the dental chair and the armamentarium to be used
tolerating instruments in his mouth)

Patient’s physical condition (inability to open the mouth, gag

2** 2**** Completing the paper-work
reflex, systemic diseases, allergies)

3** Patient’s body conformation (too tall, overweight) 3**** Scheduling patients and communicating with them

4** Invalid answers- not indicating patient related causes 4**** Taking dental X-rays

Not enough theoretical knowledge and not respecting all the

1*** 5**** There are no time consuming activities
treatment protocol steps
[Table/Fig-2]: Questions and answers. (The students had the possibility to chose multiple reasons for their difficulties to respect the ergonomic principles)

Students most often associated ergonomic challenges with working

[Table/Fig-3]: Posture satisfaction scores.
treatments. A similar study by Garcia P et al., showed that 62.1%
of the students report having difficulties in adopting ergonomic
postures due to the types of treatment required and the regions of
the mouth being treated, confirming that ergonomical difficulties are
common amongst students [17].
Journal of Clinical and Diagnostic Research. 2021 Aug, Vol-15(8): ZC33-ZC37
in indirect vision using the mirror (n=90), the lack of assistance by
a colleague as an assistant during treatment (n=52), the too short
duration of the working period (n=50) and the lack of sufficient
space around the dental unit (n=43).
Present study indicated that the main reason for not applying the
principles of ergonomics was due to difficulty in working in indirect vision,
a skill which, in student’s opinion, is insufficiently mastered by them.
This is an aspect addressed by another study that suggested the
introduction of indirect vision training as early as possible [18]. Good
indirect vision skills are demonstrated to improve head and shoulder
posture, as well as back posture and contribute to the prevention
of rounded shoulder [19]. Moreover, using magnification systems,
like dental loupes or the dental operative microscope is shown to
significantly improve the posture, but unfortunately students don’t
use them during clinical work [20].
Some patient-related factors (rushed patient, low instrument
toleration, inability to open the mouth, respiratory difficulties,
35
 Marius G Bud et al., The Ergonomical Challenges Students Face while Working in a Clinical Setting www.jcdr.net
sensitive vomiting reflex, patient’s stature) can sometimes prevent
students from achieving good ergonomics as indicated by 15% of
students.
Some of the identified causes are related to patient education
including communication gaps or reluctance, induced especially
by the lack of patients’ habituation with the rubber dam system
and the discomfort of sitting in a horizontal position. Moreover,
statistics shows that operator experience improves patient
compliance [21]. Patient compliance may be a transitory problem
which can be solved by gaining experience and may also be
related to patient’s satisfaction. Regarding the satisfaction of
patients treated by dental students, Azimi S et al., identified a
close link between student gender, patient education level and
patient satisfaction level [22].
Although isolation is of major importance for the prognosis of a
treatment, the rubber system has been less used in endodontics
in the past in Romania [8]. According to the results of this study,
almost all students used the rubber system in all cases (n=102;
91.98%) but half of them (n=55) stated that they encountered
difficulties in positioning the clamp and the foil on difficult teeth or do
not have the appropriate tools or enough experience. The reasons
for reluctance stated by students are related to the extension of
working time and the patients’ preference to be treated without
a dam. These reasons are also identified in other similar studies
[23-25]. However, these studies showed that patients perceived
an increase in comfort when treated with dam isolation and the
average application time is short, ranging from less than 2 minutes
in the case of experienced physicians to 4-5 minutes in the case
of students [23-25].
A quarter of the students considered that they possessed the
theoretical knowledge necessary to establish the diagnosis,
treatment plan and implementation of the operating protocol
in  all treated cases. Two-thirds reported feeling confident in
almost all cases. Even so, most of them (n=71; 63.96%), declare
to frequently ask the supervising dentist for advice because they
consider themselves not having the necessary experience  to
find satisfactory answers on their own and develop rational
treatment plans. This may indicate a difficulty in applying the
theoretical knowledge in decision making situations or a low
level of self-confidence of the students. This is in agreement
with Alrahabi M, who found out that students felt more or less
confident while treating endodontic cases depending on the
stage of the treatment, feeling more confident when preparing
the access cavity and during the restauration of the treated
tooth than when instrumenting the tooth canals [26]. Moreover,
the students/supervisor-dentist ratio of 9:1 is a favourable
one, aiding students to easily interact with the supervisor. In
a statistical study conducted in 28 dental schools in Germany
in  2008, Sonntag D et al., indicated a numerical ratio of
students  supervising-dentists between 9/1 and 30/1 [27]. The
number of hours of preclinical practical training varied between
12 and 60.
More than half of the students rated their cases as being of little
or medium difficult level. These results are showing a high level
of confidence from the students, compared to similar studies
published in the literature [28,29]. These studies revealed lower
levels of confidence in solving endodontic cases, but in such cases,
the notion of referring more difficult ones to the specialists appears
to be better understood by the students.
Limitation(s)
Possible limitations to this study were the relatively narrow group of
targeted students, since only students in their year of study were
included. It might not accurately reflect the situation of students in
36
their final year of university. Another limiting factor was that sample
of students was taken from the students studying at the same
university, so findings may not correspond with other universities
studies.
CONCLUSION(S)
The results indicated that students encountered multiple
challenges both with working ergonomically and with mastering
the practical skills needed in different stages of the treatment. They
showed high levels of confidence in their theoretical knowledge
and with establishing the diagnosis with a treatment plan, but
most of them struggle when it comes to adopting an ergonomic
working posture.
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PARTICULARS OF CONTRIBUTORS:
1. Doctor, Department of Conservative Odontology, UMF Iuliu Hatieganu, Cluj Napoca, Cluj, Romania.
2. Doctor, Department of Conservative Odontology, UMF Iuliu Hatieganu, Cluj Napoca, Cluj, Romania.
3. Doctor, Department of Conservative Odontology, UMF Iuliu Hatieganu, Meteor 4/46, Cluj, Romania.
4. Doctor, Department of Conservative Odontology, UMF Iuliu Hatieganu, Cluj Napoca, Cluj, Romania.
5. Doctor, Department of Oral Rehabilitation, UMF Iuliu Hatieganu, Cluj Napoca, Cluj, Romania.
6. Doctor, Department of Conservative Odontology, UMF Iuliu Hatieganu, Cluj Napoca, Cluj, Romania.
7. Doctor, Department of Conservative Odontology, UMF Iuliu Hatieganu, Cluj Napoca, Cluj, Romania.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Marius G Bud, •  Plagiarism X-checker: Jan 15, 2021
Salcamului 21, Cluj Napoca, Cluj, Romania. •  Manual Googling: May 24, 2021
E-mail: mariusbud@mbdental.ro •  iThenticate Software: Jun 09, 2021 (4%)

Author declaration:
•  Financial or Other Competing Interests:  None Date of Submission: Jan 13, 2021
•  Was Ethics Committee Approval obtained for this study?  No Date of Peer Review: Mar 17, 2021
•  Was informed consent obtained from the subjects involved in the study?  Yes Date of Acceptance: May 25, 2021
•  For any images presented appropriate consent has been obtained from the subjects.  No Date of Publishing: Aug 01, 2021

Journal of Clinical and Diagnostic Research. 2021 Aug, Vol-15(8): ZC33-ZC37 37

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